PCOS: The Signs Your Doctor Might Be Missing

The following podcast is a deer media production. There are millions of women out there that are trying their best to find that calm but they just can't get to it. Not because they're lazy, not because they're challenged and they can't meditate, not because they're not putting effort into it. They don't get there because metabolically no one's addressed their underlying condition. It affects 15% of women but 75% of them go undiagnosed. I think they're more people walking around with PCOS, they either have never heard of it or they just don't know what it is. I love our Ask Dr. A episodes because I love having our guests and it's amazing to have these incredible medical minds and scientists but you are the reason that we started a GMD because you are an incredible mind in women's health and for people that haven't listened to all of our podcasts, the origin story is in the reason that the light bulb went into my head that we had to do this together was you started talking about PCOS. PCOS, we talk a lot about it, it's one of your life's missions, it's become one of my life's missions to really help women that are, you know, it's a leading cause of infertility, again we'll get into all of that today. So welcome to the podcast. Dr. Alia Vadi. You're having me. Let's start at the beginning. What is PCOS? So PCOS, polycystic ovary syndrome is a condition that affects 15% of women and it's not just about infertility or irregular period. It's a condition that affects our metabolic health, hormone health, inflammation and it has a psychological complication that comes with it. So it's a whole body condition and you can't just use one symptom and describe this condition. It's very complicated because different patients present differently. There are different phenotypes of PCOS and that's why it's so hard to diagnose because every patient presents differently. It's the most common hormonal imbalance condition in women in their reproductive age and like I said, it affects 15% of women but 75% of them go undiagnosed. In my opinion, that 75% is an underestimation. I think there are more people walking around with PCOS. They either have never heard of it or they just don't know what it is or their symptoms get dismissed. That's that blew my mind. 15% of women, you think it's higher than that, but go go undiagnosed. Why? Why is it so hard? Because so many women present differently. When you want to diagnose PCOS, you have to meet two out of the three criteria, right? The first one is hyperandrogenism. What does that mean? It means elevated levels of androgens or testosterone. So these we go by symptoms. You do not need to have a high testosterone in the blood to get the diagnosis. Meaning what are these symptoms? Acne, cystic acne usually in the jawline, hair thinning, facial hair body hair being the most common. These are women who constantly go for lasers and the hair keeps coming back. These are the most common signs of high testosterone. So that's criteria number one. Criteria number two is an ovulation or ovulatory dysfunction. These are women who have irregular periods, meaning they have their periods every 35 days or more, or they have less than eight periods per year. So their periods are less frequent because they're not ovulating. That's the second criteria. And the third criteria is the ovarian morphology, the polycystic ovarian morphology. What's a morphology? It's the way the ovaries look on ultrasound. So basically when you do an ultrasound, these ovaries we call them string of pearl. Basically, there are follicles that have been frozen and they haven't been released with ovulation that they stay in the ovary and they look like sack of pearls. So they're bunch of these little cysts throughout the ovary. It's very specific to PCOS, but then again, a lot of clinicians either don't do an ultrasound or when they do an ultrasound, they miss this morphology. So that's the third criteria. This third criteria is not used for teenagers. Obviously, teenagers have tons of follicles, so we don't use this third criteria. Recently, as of a few years ago, well, we added an elevated egg count to this third criteria for adults instead of ultrasound. If your doctor hasn't done an ultrasound, if you don't know what your ovarian morphology is, using a high egg count AMH, which is a simple blood test you can do at your doctors, can meet this third criteria. Now, you need two of the three to meet the diagnosis of PCOS. And that is why different patients present differently. The most common morphology of PCOS, they meet all three criteria, meaning they have irregular periods, they have symptoms of high testosterone, and they have PCOS looking ovaries on ultrasound. The second phenotype are patients who have the irregular periods. They have the symptoms of high testosterone, but they have a normal ultrasound, and they don't have PCOS looking ovaries on ultrasound. The third morphology, these are patients who have regular cycles, but they have PCOS looking ovaries on ultrasound and high testosterone symptoms. And the last phenotype are patients who have irregular periods and PCOS looking ovaries on ultrasound, and they have no symptoms of high testosterone. So that imagine different patients presenting with these four phenotypes, one person can have acne and irregular period. The other person can have normal periods with acne and PCOS looking ovaries. The other person has facial hair body hair, or high testosterone in the blood, but it's important to understand that you do not need to have a high testosterone in the blood to get the diagnosis. Yesterday, I had a patient in my office saying that her endocrinologist told her she doesn't have PCOS because her testosterone are normal, so we don't go by blood. We go by symptoms of elevated testosterone. So that's how you diagnose PCOS. PCOS patients have weight issues, which we're going to get into that. 75% of them gain weight. Many of them have family history of someone in their family with PCOS diabetes, gestational diabetes, overweight family members. They are at risk for binge eating and disordered eating, which I'm going to talk to you about and why this happens. And many of them have fertility issues because their underlying condition is not addressed. 70 to 80% of PCOS patients do not ovulate every month. And even of the patients with regular cycles, many of them do not ovulate still. And we can talk about that too. So that was a question that we got a lot from our listeners is the weight. What causes the weight game? And I remember when we first started talking about PCOS, you said a great example is you have two sisters or a bunch of sisters. Three of them can eat anything they want and they can exercise during their teenage years. And the other one, you know, the moment she gets her period, she all of a sudden, she puts the same piece of pizza in her mouth and can't lose the weight. So what causes the weight? So if we think about it, majority of PCOS patients have insulin resistance. And to make it simple, the way I explain it to my patient is that the first domino, the drops that starts a cascade of events in a PCOS body, that first domino is insulin resistance. 70 to 80% of PCOS patients, who are overweight have insulin resistance, 25% of PCOS patients, we call them lean PCOS, even lean PCOS patients have insulin resistance at their tissue level. So it's very important to understand this insulin resistant domino, the first tile that drops. When we eat carbohydrates, our body breaks it down into glucose. Glucose stimulates our pancreas to release a hormone called insulin. The job of insulin is it acts imagine on your muscle cells, on your liver cells, they open up these receptors on the surface of these cells to grab the sugar out of the blood, put it into the cell and turn it into energy. This is what's supposed to happen when we have carbohydrates when we eat sugar. What happens in PCOS because they have insulin resistance when they eat this sugar and their insulin gets secreted, their cells are insulin resistance, meaning these receptors, these channels don't open up to pull the sugar into the cell and turn it into energy. So what happens is sugar bounces into the blood and raises our insulin. When insulin goes up, few things happen to a PCOS body. Number one, high insulin stimulates the liver to take this sugar and turn it into fat. But you have to understand the fat that's stored from elevated insulin and insulin resistance is a visceral fat. Visceral fat is a fat around our organs. It's different than the fat that we deposit right under our skin. This fat is highly inflammatory. It releases cytokines in the body that increases the inflammation in the body. What's the cytokine? It's these inflammatory markers that get released from the visceral fat. So what happens is, as the inflammation goes up, it makes our insulin resistance worse. So this vicious cycle happens. Then our liver usually produces a sex hormone binding globulin. This is a protein in the blood that grabs on to the free testosterone in our blood. When insulin goes up, the production of sex hormone binding globulin goes down in PCOS patients. So you have more of the free testosterone available in the blood that can cause all the symptoms that we just talked about. That's the first part of insulin going up. When insulin goes up, it does one more thing to a PCOS ovary. PCOS patients are resistant to insulin everywhere else in the body, but their ovaries do the opposite. They're hypersensitive to this insulin. Insulin, when it goes up in a PCOS patient, it stimulates their ovaries to release androgens like testosterone. So now this first domino that drops, which is insulin resistance, causes our insulin to go up, causes our visceral fat to go up, causes our inflammation to go up, and stimulates our ovaries to release testosterone. So now you have this vicious loop of insulin resistance that keeps going, the patient keeps gaining weight, right? And the ovaries, because of that high insulin, keep pumping testosterone out. That's when the second tile drops, which is now you have this metabolic cycle going, and the second vicious cycle is this hormonal cycle that kicks in. And it's caused by the metabolic, it's fueled by the metabolic dysfunction. So now that you have these antigens or testosterone secreting in the ovary, testosterone is toxic to these little follicles that are trying to mature every month, and one of them wants to ovulate, right, and get us pregnant. So what happens when the environment in the ovary has testosterone, these little follicles freeze, and they don't release, right? So what happens, A, we don't ovulate, patients can't get pregnant. B, these follicles start staying in the ovary, they cause an inflammatory process in the ovary, so it makes the environment inflammatory. And the third thing they do is they start secreting erratic levels of estrogen. In a normal menstrual cycle, we have the follicular phase where the estrogen goes up, and this elevation of estrogen secretion from healthy follicles gets the lining of the uterus thick and juicy ready for pregnancy. Then mid cycle, this increase in estrogen stimulates a part of our brain, which is the hypothalamus and the pituitary gland, to release GNRH, it's a hormone from the hypothalamus, it stimulates the pituitary gland. Then the pituitary gland releases mid cycle, this hormone called LH, luthanizing hormone, which causes an ovulation. And once we ovulate, this cyst that stays behind in the ovary, releases progesterone to protect the lining of the uterus and protect that embryo for pregnancy. But this doesn't happen in PCOS patients. So what's happening now? You have this testosterone in this environment that's freezing these follicles that one of them was trying to mature and release, so you don't have that release. These follicles are making erratic amount of estrogen. But what this testosterone does, it stimulates that same hypothalamus that was releasing this GNRH hormone that affects the pituitary gland to release FSH and LH, what happens with testosterone and this abnormal estrogen feedback is the GNRH that comes from the hypothalamus starts firing really, really fast. When this happens, the pituitary gland instead of just releasing LH for ovulation, it starts releasing this hormone constantly throughout the month. While this LH stimulates the ovarian tissue, these thicker cells in the ovary to secrete more testosterone. So now you have this vicious cycle of testosterone and hormonal imbalance going on, which has erratic levels of estrogen, it has low progesterone and high androgens. So now this is the second loop. You know, for years, I tried skincare that promised the world and delivered nothing. I'd slather on products loaded with ingredients I couldn't even pronounce chasing some miracle that never showed up. 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The insulin resistance, the visceral fat, the high androgens, the low estrogen, all of it together, they stimulate an inflammatory process in a PCOS body. This inflammation is what really takes them down. They feel tired, they feel bloated, they have brain fog, they just don't feel well. This is now a chronic inflammatory vicious cycle that starts happening. Do you understand how everything is crazy? It's the body is incredible. The most fascinating part is how how these three vicious loops affect these patients psychologically. And I want to describe that because patients don't get it. So let's start with the limbic system. limbic system is the emotional headquarter of our brain. So this is where all of our emotions are stored. Anger, happiness, irritability, sadness. And anxiety. We have this limbic system, which is the hypothalamus, the hippocampus and the amygdala. All of our emotions are in here. Now we have a prefrontal cortex that works as a break to control the emotions that come out of this limbic system, right? This limbic system, in order to be calm, it needs normal levels of estrogen. It needs progesterone. It needs low inflammation. And it needs low androgens or testosterone. What do we have in PCOS? Irregular estrogen, low progesterone, high inflammation, and high testosterone. So now you have a limbic system that's on fire. What does this do? It lowers our serotonin in the brain. Patients get anxious, depressed. They get food cravings. They have binge eating. It affects their amygdala. They become anxious. They are fearful, irritable, sad. It affects their hippocampus. This inflammation that happens causes a brain fog, memory issues, concentration issues. So now you have this limbic system, this patient that's anxious, depressed, unmotivated, has brain fog. She doesn't function well. She's just sad. She's constantly craving food. She's binge eating. Now you need the prefrontal cortex to put a stop at it. So you're going downhill 100 miles an hour, and you need the break to work, right? What does the prefrontal cortex need? It needs normal estrogen levels, low androgen levels, low cortisol levels, which is high in PCOS patients. It needs good sleep, which patients are not getting. PCOS patients are not getting good sleep. Their sleep is fragmented. It needs low stress. And on top of that, it needs supplements like vitamin D, iron, omega-3s, and B12. So now you have this limbic system on fire, and your prefrontal cortex, the break is not working. That's why these patients spiral. They have eating disorders. They have anxiety, depression. But what happens to them when they're a teenager? They're gaining weight. They feel inflamed. They have acne hair, loss facial hair, body hair. They're anxious, depressed, imagining these four pillars, acting all together, brain fog, binge eating, all of it. And they end up in a psychiatric unit at an eating disorder center. Because no one addressed that first-- - Root puzzle. - Yeah. - That first tile that dropped. What do they do? They go to the fourth pillar of psychological issues, and they put them in eating disorder centers, and they have an SSRI, or that's exactly what they do. And that's why the SSRI doesn't help them. Oh, by the way, I forgot in this last pillar, PMS, PMDD. That's why when you fix their metabolic health, when you lift that first tile, everything else starts falling into place. These are patients who, for example, take OV. You put them on metformin. You put them on GLP1s. Everything that addresses insulin resistance, they come back and they're like, "Doctor, my PMS is better. And my anxiety is better. I love my soft more. I feel more comfortable. My inflammation is less inflamed, but all of it makes sense." - It's like the chicken and the egg. And before I knew about PCOS and all these things, I would think, or even when I first started learning from you, I would think that the anxiety and the depression all that was because their body wasn't working properly. And how horrible must that be to eat the same thing as your sister? - But that's true, too. That's exactly the fact that it's the double whammy. - Yes. - But the way you just described it, it really is about systems in your body not working properly. And if you fix the root of it, which we're going to talk about how to do that, then the dominoes stop. - You know, when I went on J. Shetty, as soon as I sat down on my J for years, you've tried to teach women to find calm, right? Do this and you'll find calm and do that. And I told him, I'm here to tell you that there are millions of women out there that are trying their best to find that calm, but they just can't get to it. They don't get there because metabolically, no one's addressed their underlying condition. So this limbic system and their prefrontal cortex is not functioning. So they're anxious and depressed and they can't focus and they can't concentrate. They can't get to that calm and they get so frustrated. - I also was going into my mind as you were talking about this, which I've never thought about, which is why I love my Dr. A episodes, because I learned so much too. When you describe PCOS, 80% of what you're describing sounds like perimenopause and menopause. It's the brain fog, it's the insulin resistance. So imagine somebody listening to this, maybe a mother who doesn't have PCOS and has a daughter, imagine having menopause symptoms from the time you have your period. - Except they don't get hot flashes and nights wet. - Well, they don't get hot flashes and nights wet. - But those aren't the bad parts. You know, it's the anxiety. - Look how much women complain when they get to perimenopause of their weight, right? Because 50% of us are walking around with insulin resistance, even without PCOS. And as we get closer to menopause, we become more insulin resistance. These are 12-year-olds who have insulin resistance. 12-year-olds eat and they cannot lose their weight. But this dismissal, the reason I speak up, the reason I want to grab this mic and just scream is because I want to save these young girls. For me, those teenagers are my top priority. The problem is you have to be careful diagnosing PCOS patients in teenagers, because like I said, you cannot use that third criteria of ovarian morphology in teenagers. But if you have a teenager who has irregular periods all the time, who has acne, facial hair, body hair, anxiety, depression, binge eating, eating disorder, you know, weight gain. And she's exercising like six times a week and she's not losing weight. You can absolutely suspect PCOS in these young girls and address their metabolic health. Because if you lift that first tile and you help them metabolically, then the endrogens get better. Because if you help with insulin resistance when insulin drops, then your ovarian secretion of testosterone drops. If testosterone drops A, they start ovulating, their periods become more regular. And as their antigens or testosterone drops, their acne gets better. They facial hair, body hair, hair thinning, hyperpigmentation under their armpit. All of it will get better. - Do you understand? - Yeah. - And once you fix that, then their inflammation goes down. As the inflammation insulin resistance and antigens get adjusted, then their brain health. - It's incredible. - Recover. - So, I remember the day that you came to me and you said, "Meryalis, I was learning about PCOS, we were starting this podcast." And you said, "There are supplements that women can take, young girls can take that are all natural supplements that will work to fix this metabolic issue." But you have to take 16 of them, 12 of them, this huge amount. - Yeah, yeah, yeah. - So you said, "I need you to go out and find a scientist." - Yeah. - And I wanted my mission is to create something that every woman can do and take without a prescription without having to see a doctor. Once they learn that they have PCOS, because it's not something that you actually need a medication to fit to help fix this metabolic issue. - So I went out and found two of the best scientists in the whole world and made my dream come true. - And I did and as a result, so we created OV and hopefully everybody's heard about OV. And I'm not talking about OV because we created it and we wanna sell a supplement. I'm talking about OV because it works and because what we created on the site are the list of questions that you give every single person that comes to your office so that you can go on for free. And if you don't even wanna take OV, just get validated and go in there, put your symptoms in. And then we created this, I call it a miracle supplement because just because of the feedback and the DMs and women that are ovulating for the first time in their life, women that are losing weight, women that are, their acne's getting better, women whose inflammation is going down, their PMS is going down. I mean, it's like every single day we get these women that come and say that it's changed their life. - The problem right now is 75% of patients are not diagnosed, I think that number is more. I had a patient yesterday, I told you, her endocrinologist told her your testosterone's not high in your blood. blood, I don't agree with your gynecologist, you don't have PCOS. So we have to A, start educating. People need to know, doctors need to know how to diagnose PCOS, okay. You do not need to do a lab test to diagnose PCO. And you don't have to have a cyst on your ovaries. You don't have, so you don't have to have PCO looking ovaries on ultrasound to get diagnosed. So you have to know the criteria for diagnosis. That's number one. If your doctor is not familiar with PCOS, if you feel like you're listening to this podcast and your symptoms have been dismissed, go on ovii.com, take the quiz. The quiz is there, it's free, at least get validation. Because once you know you have it, and I just literally explain to you the four most important pillars of PCOS and why these things happen to PCOS patients, then you can become your own health advocate. Because majority of PCOS patients have this underlying insulin resistance, by the way, it does not need to show on your lab result again. You can't come to me and say, but my hemoglobin A1C is normal, so I don't have insulin resistance. It's at tissue level, and when your young your body clears that sugar fast. So as you get older, it starts showing up in your blood, so you don't really need to have an abnormal value, there's specific tests that you can do, like the HOMA IR, but a lot of doctors don't perform these more specific insulin resistant tests, and they just do a hemoglobin A1C. And just by doing that test, you cannot say, oh, you don't have insulin resistance. So once you diagnose PCOS, you have to address the metabolic health issue, which is the insulin resistance. So I always start by telling these patients, if you take the test on ovii.com, and it says you have a high likelihood of having PCOS, then I would say address your metabolic health. Make sure you're eating healthy. Make sure you're not eating processed food. Make sure you're not eating a lot of sugar. Make sure you know that your body does not process carbohydrates well. That's step number one. Number two, exercise is very important. When we exercise, we open up these receptors, we stimulate these insulin receptors on the surface of our muscle cells, and they start pulling the sugar in. That's why we tell diabetics, go walk for half hour after you eat. I think for PCOS patients, it's very important after each meal, go walk 10-15 minutes. Stimulate those receptors to wake up and pull that sugar into the cell, because by doing that, you lower the insulin. So diet makes a huge difference. Exercise makes a huge difference. Number three, you want to address insulin resistance. So I always start with supplements, just like before jumping to surgery, you want to do non-surgical options. In PCOS, you want to start with non-prescription options. In the past, patients would just take an acetal or myoan acetal. These are supplements that help with insulin sensitivity, and that's why it helps patients have regular cycles, and their symptoms improve. However, that alone is not enough. Even when I was talking about the brain, like, you know, vitamin D is important, knowing your vitamin B12 levels are important, knowing your iron level is important. What is your ferritin level? Because all of these affect vitamin D also affects your insulin resistance. Let's say you have a patient who is, I don't know, 100 pounds overweight. I start them on OV, and I usually start them on GLP ones. I started doing this in 2014 with the GLP ones. So GLP ones, like ozempics, and wagovis, abound, mongaro, sacsenda, you name it. These medications, what they do, they work not only by suppressing appetite, appetite suppression is secondary, but they regulate your insulin. So basically, instead of having your insulin be up all day, causing storage of fat, they spike your insulin to go up when carbohydrate load comes into the body. But also, they affect, they help with insulin sensitivity. So at a tissue level, just like the OV supplement, both work at a tissue level to help with insulin sensitivity. That's number one. I give OV to my patients before their heaviest meal, because if you take it before your heaviest meal, it blocks the absorption of carbohydrates by 40%, which is significant. So now if you have a low carb diet, and let's say the one night you want to go and have pizza or pasta, take your OV right before that meal, then go for a walk 10 to 15 minutes. If you take these little steps, eventually not one of them will do magic. You kind of need to do all of it together. So going back to that patient who wants to lose 100 pounds, besides diet, exercise, OV supplement, I start them on GLP ones. And in about three to four months, usually my average in four months, patients doing OV and the GLP ones, they lose about 24 to 26 pounds in four months. 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That's wherefigs.com code figs rx. So then I start them on metformin, then I keep them on OV, G.L. P1 and metformin until they get to their goal, once they get to their goal, I start dropping the GLP1 and I maintain them on OV or metformin. The issue with metformin and/or or both, both together. I do the three together and then two together. The issue with metformin is for some patients it causes severe nausea and some diarrhea. So the compliance with it, I take metformin, I have no symptoms, I never had symptoms of it. But then some patients get really sick. So for those patients then I keep them on OV, if they can't stay on metformin, then I keep them on a low dose of GLP1, maybe twice a month, maybe once a month, maybe once a week on a lower dose, every patient is different. So it can't just put every single patient in one basket and say this is how I treat you. In addition to all of this, there's some PCOS patients who have acne. When they're young, where do they end up in the dermatology office, what do they get? Acutane. In 25 years, I've never, ever treated any patient with acutane. Because if you fix their metabolic health, if you address their insulin resistance, their testosterone levels drop, so that helps a lot. If you put them on medications, you can, besides metformin and OV, you can give them Spirinol Actone, which is an anti testosterone. It helps their skin super fast. I usually start 50 milligrams once a day, and then I increase it as needed to twice a day. You can go as high as 100 twice a day. But most of these young girls do really well with 50, 50 milligrams twice a day, if they're doing their OV and their metformin. Now, PCOS patients, you've heard, as soon as someone says, maybe you have PCOS, oh, your periods are irregular, doctors automatically need your reflex, give you birth control pill. Now birth control pill works well with these patients, why? Not only birth control pill affect that LH hormone that I was telling you. These patients, especially the ones who have completely irregular cycles, it stimulates their periods to come once a month. So that's important, it's a form of birth control. That's important. Remember, I told you, for patients with insulin resistance, when their insulin goes up, their liver produces less of this sex hormone binding globulin, which grabs onto the testosterone. While birth control pills stimulate that sex hormone binding globulin, and by stimulating it, now you have more of these proteins in the blood that grab onto the free testosterone and help resolve the symptoms of high testosterone. Like acne, facial hair, body hair, all of it, right? So birth control pills have a place in the treatment of PCOS. Unfortunately, in my personal experience, because of that psychological aspect of PCOS, a lot of patients do not tolerate systemic birth controls. You put them on birth control pill and they call back and they're like, it made me sad, it made me anxious, I don't feel good on it. So I offer it to them, but especially the ones, let's say, slinned birth control is a good birth control to use for PCOS patients because it's progesterone only, but it's highly anti-androgenic. So that's a good one to use, yes, birth control is a good birth control to use for PCOS patients who have PMS or PMDD because it helps with their PMS or PMDD. So again, they're different birth control pills that you can use for different patients. You have to remember when overweight or obese patients who don't ovulate and they don't get their periods regularly, they are at risk for uterine cancer and uterine hyperplasia, which is pre-cursor to uterine cancer. So you do want them to shed their lining once a month. And that's why the importance of birth control comes into play. Also the importance of dropping their weight and fixing that metabolic issue to regulate their period so they don't have a built up of lining inside the uterus that can turn into uterine cancer later. Well, again, a lot of the feedback we've gotten from so many women was I started taking OV and I'm ovulating for the first time in my life regularly. Explain to me why. It's because we dealt with your metabolic issue. We made you more insulin sensitive. Your insulin levels drop as the insulin levels drop on the second pillar. It lowered the release of testosterone from the ovaries. As the testosterone goes down, remember, those follicles don't get freeze and they don't get stuck in the ovary. They actually start growing in a normal environment and they ovulate and the period comes. So because I know from being around you a lot, it'll drive you crazy when you see somebody on another podcast and they say, "How you fix PCOS is to give them birth control." It drives you crazy because they're not fixing the issue inside the metabolic issue. So it's sort of this thing where it's not one thing, like you said, PCOS patients aren't just one kind of, they don't, they don't, it's a whole body, it's a whole body system. You have to address, you have to address the metabolic health. You have to address the hormone imbalance. You have to address the inflammation and you have to address the psychological changes that comes with it. You have to address all of it, otherwise your patient doesn't feel good. If you throw birth control at them, they're still gaining weight, they're still bloated, they still have their mental health issues, they just get regular periods and their acne gets better. Yeah, it doesn't do anything with their growth. It helps with their testosterone, but you haven't addressed underlying condition. If I had to pick one thing that I could fix, one thing in a PCOS patient, I would lift that first tile and that would be insulin resistance, I would fix that. And then the rest of it starts to work properly and then your body gets back into balance. I mean, I was, you know, when we were sort of thinking of ways to talk about it, it was just like, it's not you, it's your body, it's not your fault, your body's not working properly. So let's get it back into motion. So even the cravings, it's not like they're just, you know, they can eat something and then five minutes later, they crave chocolate or they crave ice cream or they crave some, they're not doing it on purpose. You can't send them to a psychiatric unit to teach them how to eat. Right. And you put me on OV. I mean, I was going to take it anyway, because I'm not going to take it. I take it. I present something because I'm perimenopausal and because I'm insulin. So again, that's what struck me earlier in this conversation was that there's so many similarities between the symptoms of PCOS and the symptoms in terms of that, your metabolic issue. And one with metabolic issue can take OV, right. So any, anyone, so 50% of us are insulin resistant. As we get to menopause, that becomes worse. That's why perimenopausal women say, I'm eating the same thing. I'm exercising the same amount, but I'm gaining weight. Yes, you have to eat half exercise twice just to maintain your weight. Forget about dropping it. Look how thin I am. I've never, ever, ever been overweight 20 years, 30 years ago, I was 25 pounds lighter than what I am right now sitting here. But if you did my blood a year ago or two years ago, I was insulin resistant. I was, my hemoglobin A1C was 5.6. I was 0.1 away from being pre-diabetic, even though I've never been overweight. Your genetics are your genetics, and you cannot change that. So I take med form and twice a day, I take OV once a day. I mean, you have to address your metabolic health no matter what because PCOS patients are at risk of high blood pressure, diabetes, cardiovascular, obviously their weight gain is an issue. You know, their 220 conditions, disease is associated with obesity. So fixing that is preventative medicine. Yeah. They're at risk for uterine cancer, eating disorders, psychiatric issues. So it's so important to address this metabolic health, and I can't say it enough. And that's why I get so upset when someone, you know, we listen to a podcast together. And they said, oh, the first line of defense is, no, breast control, and she ended it. Yeah. So can we talk about fertility? Because that's the other thing that shocked me. PCOS impacts your fertility and egg quality. Can you talk about that? Yes. So remember, you have these frozen follicles. So when you do an ultrasound as a gynecologist, you're going to say, oh my god, you have a 35-year-old. You're going to say, oh my god, you have so many eggs. But those are poor quality follicles in there, right? They're frozen in a hostile environment in the ovary. So that egg count for PCOS patients is usually very high, because these follicles are secreting the AMH hormone, but they're really not ovulating, right? So the biggest issue with PCOS, number one, when it comes to fertility, number one, is 70 to 80% of these patients are not ovulating. Of the women who have regular cycles, a lot of them could also not be ovulating. They're having these periods, not because of progesterone withdrawal from ovulation. They're getting it because of that estrogen imbalance that they get withdrawal bleeding. So that's a group of patients. So ovulation or an ovulation, I should say, ovulatory dysfunction is very common with PCOS patients. And again, we learned that if you address your metabolic health and lower that insulin, you can lower the androgen. And by lowering the androgen, you increase the chance of ovulation. So you could have your period every month and not be ovulating. Correct. With PCOS. Yeah. Number two is the egg quality. So when I have a PCOS patient, even if they have a lot of ovarian reserve on the their blood tests on ultrasound, I usually tell them to freeze their eggs because of that quality issue. These are patients who sometimes show up to my office at age 40 and they're really matter their fertility doctor and they come to me and they're like, "I can't believe that they pull out, I don't know, 25 eggs or 30 eggs and I couldn't make a single embryo." Well, at 40 if they're pulling 25 or 30 eggs, that's PCOS and the quality is really poor. As we get older, we're born with millions of eggs and as we go through life, we destroyed them. When we get to menopause, we have a thousand of them left. So I have two. Yeah, probably have none because my ovaries are up. So it's important to know that this is not something you can just say, "Oh, I'm good, I'm good, I'm good." If you are not ready, if you have PCOS and you don't have a partner and you can afford egg freezing, that's the limiting part because many people can't afford it, I would say definitely freeze at the latest by 32. By 32. Even though we tell patients 35 with PCOS, I'm a little bit more aggressive because of that quality. So you have ovulatory issues, you have egg quality issues. The third thing is, remember, we talked about inflammation, testosterone, estrogen, secretion, that's not perfectly following the menstrual cycle, all of these cause and hostile environment in the uterus. So risk of miscarriage goes up, implantation will have issues. So that's another issue with PCOS patients. In my opinion, at least 50% of PCOS patients have endometriosis and that's my personal observation and I have path reports to show it, honestly that number could be even higher than that. So whenever I see PCOS, I always, always, always look for endometriosis because you don't want to miss that because endometriosis is another top cause of infertility and it does cause an hostile environment in the uterus, it does affect a counten quality, it causes a new inflammatory process in the pelvis that when the egg gets released, it's not picked up by the tube, maybe the tubes are blocked. So just together, the two of them are the leading cause and imagine you have a lot of these patients that have both of them. We did a fertility podcast, I would recommend patients listening to that but you really have to really spend some time with these patients, do the correct tests on them and guide them correctly. So when they're ready to have children, if that's what they want, not everyone wants to have children, that their body is ready and responding to it. And that's why when this GLP1 epidemic blew up, patients were like, I'm getting pregnant, I'm getting pregnant because what is it these GLP1s were addressing the insulin resistance, patients were dropping their weight and were starting to ovulate and they got pregnant. So we talked about this at the beginning but I think it's really important to say this one more time very clearly with teenagers, how do you diagnose PCOS? So I'm very hesitant to diagnose teenagers but then again, because you can use the ovarian morphology and teenagers sometimes have irregular periods, it's common for them to have acne. But teen PCOS patients present with a lot of other symptoms around it. They're gaining a lot of weight, they're exercising, they're eating healthy, they're binge eating, they're anxious, they have irregular periods, they're lasering their hair, they have really bad cystic acne that's not responding to anything, sometimes you do a blood test and their testosterone is really high. So you look at the entire picture and you still treat them, right? Because if you have an overweight teenager, you want to address her metabolic health regardless of what the diet and I don't care as much about giving them a diagnosis, I want to treat their symptoms and I want to give them that confidence back. The worst thing that can happen to a teenager is a teenager that's anxious, depressed, has self-esteem issues and has eating disorder. It cannot get worse than that for parents. And I'm telling you today that if I had a twin of mine, the first thing that twin would do would go knocking on the doors of these eating disorder centers. And I would pull all the PCOS patients out. But it's important to know that we talk about this a lot, PCOS is not a fertility center. Absolutely not. PCOS patients get pregnant all the time. That's why when we started this podcast, I said PCOS is not just irregular period or fertility issue. Now if you have PCOS, you want to make sure you check everything so you don't fall into the trap of infertility, but not all PCOS patients are infertile. Absolutely not. If anything, actually even at 40, they have so many eggs that you can pull a ton of eggs out versus someone who just has endometriosis and their end of destroys their account and quality and they show up at 30 and they have no eggs. And I think that one of the things that I hear a lot from people, the question is, do I have to have high testosterone in my blood type PCOS? No. Do I have to have cis on my ovaries? And I know that's the one that gets you to do. That's another one because doctors do an ultrasound and they're like, oh, you don't have a cis on your ovaries so you're not PCOS. That's why it's such a bad name for this condition. Polycystic, there's no such thing. It should be polyfolicular, I don't know, ovary syndrome, but it's not even just the cyst on the ovary. Just like I said, it affects your entire body. It's metabolic. It's hormonal. It's psychological. It's inflammatory. So you can't just summarize it into cyst on the ovary A. It's not a cyst. It's bunch of follicles that are frozen and stuck in the ovary and it's a specific finding on an ultrasound and the second most common morphology is in PCOS is women who don't have PCOS looking over his own ultrasound and they're still PCOS. So calling it PCOS is just a bad name and they are going to change it. I mean, I guess that the, again, what I want people to take away that I didn't know is that your metabolism is your master regulator and growing up, you know, you hear metabolism or insulin, insulin sensitivity, insulin resistance. You think it's for older people? Yeah, you think it's, and you think that, oh, it's just about my weight. It's just, oh, if my metabolism isn't working, I want to boost my metabolism because it's just about the weight. But it's not for PCOS patients. It's about everything. Hormone. It's everything. Okay. What do you want to leave every listener for CMD right now with if you could, if they could come up with one thing about PCOS, what would it be? Don't dismiss it and have doctors diagnose it correctly. And if you think you have all the symptoms of PCOS and if you meet the criteria, if you go on OV and you get, you know, high likelihood of having PCOS and your doctor is still telling you you don't have it, then be your own advocate. If you're a mom, then be the advocate for your daughter. Unless we diagnose, we cannot treat. So the first step is diagnosing. I want those 75%, 80% of women who are walking around struggling with all these symptoms. And they're told, eat less, exercise more. Oh, you're probably eating a lot, which is not true. I want those women to get correctly diagnosed. And then we can go to treatment. But unless you diagnose, you can't treat. CMD says it all the time, be your own health advocate, take it into your own hands, walk into your doctor's office, armed with the information that you need to be your own health advocate. So I just want to thank you for joining me on the podcast and having me. If you want to know more about PCOS, obviously go to ov.com, ovii.com. We have a lot of episodes that talk about PCOS. The Phoebe Hancock, Greg Ranford episode is an amazing episode. We do a lot of fertility episodes. So there's a lot of other CMD podcasts that you can go listen to to even get more information. But we really did want to spend today doing that deep dive. So thank you. Thank you. Thank you. Thanks so much for joining us today on CMD. If you want to own your own health, a good place to start is by following us on social media at CMD podcast and by subscribing to our show on YouTube or wherever you get your podcasts. For takeaways from today's episode, visit our website shmdpodcast.com. We'll see you next time on CMD. This podcast is for educational and entertainment purposes only. It is not intended as a substitute for a physician's medical advice. You should regularly consult your medical provider and matters relating to your own health. Even though we share our honest beliefs on CMD, some of the products and services we discuss may involve sponsorships or paid advertising.